Provider Demographics
NPI:1477197705
Name:MOSS, KELSEY-JO AUDREY (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KELSEY-JO
Middle Name:AUDREY
Last Name:MOSS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:KELSEY-JO
Other - Middle Name:AUDREY
Other - Last Name:HODGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:704B NE 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4351
Mailing Address - Country:US
Mailing Address - Phone:971-400-7350
Mailing Address - Fax:
Practice Address - Street 1:704B NE 62ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4351
Practice Address - Country:US
Practice Address - Phone:971-400-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201907307NP-PP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics